Page 56 - Journal of Special Operations Medicine - Spring 2017

for San Antonio were similar to those of 2011 to 2013. broken tourniquets work. Occasional effectiveness with
20
Although materials may seem reasonably resistant to any improvisation led to higher blood loss volumes and lon-
one pollutant, the combined action of several pollutants ger times, and ineffectiveness eventually led to casualty
can alter the materials. For example, when polyethylene, death by exsanguination. Previously, we had not run
polypropylene, polystyrene, polyvinyl chloride, polyacry- across the need for such improvisation, but user 1 ac-
lonitrile, butyl rubber, and nylon were exposed to a mix- quired more ability to control bleeding as he accrued
ture of sulfur dioxide, nitrogen dioxide, and ozone, the more experience, and was better able to simulate care-
materials each sustained deterioration in strength. The giving by continuing efforts to save a life. In the past, the
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negative interactions among individual types of exposure, user, after repeated failures, terminated the test because
such as sunlight and bird droppings, which contain cor- of persistent futility. An unexpected usefulness of this
rosive uric acid, are not fully understood scientifically. 22 limitation was its illustration of exsanguination death
by the manikin, which occurred at 2,500mL blood loss,
Recommendations based on the findings of the present a 50% loss, and such simulation may help caregivers
study include: better learn the amount of time needed to attain bleed-
ing control. If a fixed application procedure had been
• Tourniquets are best stowed in first aid kits as is a cur- followed without improvising, results could have led to
rent practice by doctrine. higher percentages of failure of tests and devices, and of
• Treat a tourniquet like a lifesaving medical device, not deaths.
like a pen or pedometer.
• Users wearing tourniquets outside of uniforms or ex- In summary, compared with unexposed control devices,
posed otherwise should be made aware of the risks exposed tourniquets had worse results, including higher
of degradation by efforts toward education, training, percentages of tests with component damage, ineffec-
and policies. tiveness, and simulated casualty death.
• If tourniquets must be exposed, the duration of expo-
sure should be minimized.
• If tourniquets must be exposed, the intensity of expo- Funding
sure should be minimized. This project was funded by the Defense Health Program
• If tourniquets are exposed, a person should be trained (Proposal 201105: Operational system management
in assessing for damage. and postmarket surveillance of hemorrhage control de-
• Exposed tourniquets may be replaced but criteria are vices used in medical care of US Servicepersons in the
unclear unless damage is extreme. current war).
• An 18-month exposure as studied is too long so such
tourniquets should be replaced.
Disclaimer
Environmental exposure should be assessed if it may be- The opinions or assertions contained herein are the pri-
come a research priority, and the relevant skill sets of vate views of the authors and are not to be construed
investigators may need determination to optimize fund- as official or reflecting the views of the Department of
ing mechanisms. Defense or United States Government. The authors are
employees of the US Government. This work was pre-
The limitations of this study are rooted in its design as a pared as part of their official duties and, as such, there is
laboratory experiment. The way the investigators tested no copyright to be transferred.
included the ability of the user to decide whether to at-
tempt to improvise with broken tourniquets, in that if a Disclosures
tourniquet broke, the user could choose to attempt to
gain effective control of bleeding by improvising tech- The authors have nothing to disclose.
niques with use of the tourniquet in its damaged state.
This improvisation occurred, but only with user 1 (sci- References
entist), the more experienced user, who conducted most
of his tests after user 2 (cadet), so the devices tested by 1. Kragh JF Jr, Walters TJ, Westmoreland T, et al. Tragedy into
drama: an American history of tourniquet use in the current
user 1 had previous wear and tear from the first test. war. J Spec Oper Med. 2013;13(3):5–25.
The very first test by user 1 led to no breakage, but the 2. Zietlow JM, Zietlow SP, Morris DS, et al. Prehospital use of he-
second test did result in breakage for some devices, and mostatic bandages and tourniquets: translation from military
so the proportion of tests with improvisation was higher experience to implementation in civilian trauma care. J Spec
Oper Med. 2015;15(2):48–53.
for user 1. User 1, thus, took more time and had longer 3. Ode G, Studnek J, Seymour R, et al. Emergency tourniquets
durations with partial hemorrhage control for the pro- for civilians: can military lessons in extremity hemorrhage be
longed efforts in trial and error to find a way to make translated? J Trauma Acute Care Surg. 2015;79:586–591.

34 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017